Provider Demographics
NPI:1962036913
Name:OMOWALE, ASHANTI (CBT)
Entity Type:Individual
Prefix:
First Name:ASHANTI
Middle Name:
Last Name:OMOWALE
Suffix:
Gender:M
Credentials:CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-5207
Mailing Address - Country:US
Mailing Address - Phone:833-971-1230
Mailing Address - Fax:253-292-1355
Practice Address - Street 1:705 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-5207
Practice Address - Country:US
Practice Address - Phone:833-971-1230
Practice Address - Fax:253-292-1355
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician